Monday, December 15, 2003

When Frustrations Threaten Your Team; also, Implementing Five-level Triage

The tumultuous past few years and the challenges posed have caused all of us to devote energy and time to our community service functions. Whether through disaster planning within our own organizations, community-wide planning as required by the JCAHO or interpreting the newest EMTALA regulations application in our local environment, we’re devoting a great deal of energy and time reacting to these external forces. Some physicians are angrily expressing the frustration that comes from the loss of control—beholden as we are to these requirements and agencies; with income and total work hours under pressure, our stressors accumulate.

Externally and within our own groups, colleagues are speaking out. Polemics advancing polarized remedies of libertarian utopian fantasies of “no pay, no service” or socialistic locked in single-payer models with no option for private sector care are advanced more as rants than as catalysts towards a solution. Meanwhile, as Dr. Kenneth Frumkin, a colleague emergency physician in a recent emed-l posting points out, adequate physician staffing is challenging at least one community-based free clinic, even if malpractice coverage is available. In some communities and regardless of our political position, as a group we are failing in our charitable responsibilities that many would assert should be our professional position. Others respond that’s because we are “forced” to deliver care for free through the EMTALA mandate.

The issues are undeniably complex; I have neither ready remedy nor the column-inches for such a manifesto if I had. Rather, acknowledging that the differences of opinion within my own practice of nearly 30 physicians may lead to tensions—often unspoken—among group members, how can I—and you—as leader of a group with perhaps similar circumstances maintain the effectiveness of our groups? Simple acknowledgment of the monumental differences of opinion among our diverse group of physician colleagues in these times only goes just so far.

Here too, I have no ready answer, but fortunately, since physicians are people and thus tend to find affinity among like-minded colleagues and with most groups smaller than my own, the likely range of opinion on these subjects is relatively small. Still, ignoring the debate outside may not suffice if even one colleague inside your practice persistently puts forward a particularly strong view.

For all the conflict differences of opinion may engender, omitting communication will engender more. So long as the discussion is reasonably focused on the activities of the group, does not include ad hominem attacks and results in an action oriented outcome, political discussion—even that constrained to a tiny fragment of the overall issue.

If you’re to have much success at this endeavor, some preparation is required.

Speak to your most outspoken colleague and offer the opportunity for the discussion. Set forth ground rules as noted above and do set a time limit for the discussion. Insist that if the discussion strays into attacks on others as distinct from differences of opinion that the conversation will stop. Most importantly, determine how the discussion illuminates an issue that you, your group and hospital must address. New regulatory “guidance” can provide an excellent motivation for conducting such a discussion since the compulsion inherent in the regulation often evokes physician frustration and passive-aggressive behavior rather than compliance with the new regulation. Vigorous discussion is a better use of the energy and may help reconcile some to the change.

Elsewhere in this issue of Emergency Medicine News a long-time professional colleague and dare I say friend, Kenneth Frumkin, MD, (the same mentioned above) discusses a “recommendation” for the adoption of a five-level triage system which is apparently pending from both ACEP and ENA. Ken demurs. I won’t restate his case; rather I suggest you read his editorial. Yes, to some degree, Ken is a frustrated physician, angered or at least challenged by the assumption on the part of these professional societies, that their recommendation should necessarily be implemented.

I respect Ken’s point of view and given our own deficiencies in the use of a five-level triage system despite my personal enthusiasm for it, experience is leading me to a grudging acceptance of Ken’s argument.

Yet, allowing that as the manager of the ED and leader of a complex interdisciplinary team I may be overly attentive to both resource allocation and management issues; I’m still persuaded of the management and planning utility delivered by the positive predictive value for resource requirements and for likelihood for admission that was the original reason for the development of the emergency severity index (ESI). If there is a three-level triage system with comparable reliability and predictive value, I'm unaware of it.

Let me explain why these factors matter to me. As a manager I would rather plan in advance and develop and rehearse contingency plans for likely eventualities. I suspect you are sympathetic to that philosophy—narrowly stated and applied—in preference to merely unplanned reaction to circumstances. We have some evidence in emergency medicine (see for example, Hoffenberg S.,, AnnEM 38(5):533-540, 2001) that explicit decision rules (i.e., “When the third ambulance gets to triage, assign nurse #2 to triage.” compared to “When the third ambulance gets to triage, a nurse should help out at triage.”) work better than a general statement at reducing length of stay.

Why does this matter? It matters because once we have the data through ESI or another reliable, validated triage tool with high positive predictive value for resource requirements and admission likelihood, we can approach hospital management with the argument that a level of demand for resources of “X” is highly correlated with negative consequences and should mandate a response other than business as usual.

Just as our practice has evolved since 1978 from accepting that half the patients with chest pain admitted to the CCU would “rule out” to today’s model of risk assessment for morbidity and mortality from acute coronary syndrome with consequent referral for care into differing clinical settings, so too might we look forward to a time when triage assessment data will help us go beyond mere counting of patients and admission rates as our only tool for retrospectively assessing our workload. Prospective evaluations facilitated by tools such as ESI may help us deploy resources more effectively and support the case for more resources at any given moment.

In the meantime, Ken may just be right as to the value of implementing five-level triage in your own ED; but then perhaps you may conceive of a larger purpose in going forward with this recommendation. Regardless, rather than merely imposing the change, perhaps some structured, if animated; discussion among clinicians in your ED may help reduce the frustration level.